Inter-tester reliability of selected clinical tests for long-lasting temporomandibular disorders

Minimum clinically important difference and substantial clinical benefit in patients with chronic temporomandibular disorders

BACKGROUND

Research on temporomandibular disorder (TMD) responsiveness is scarce and limited regarding patients' representativeness.

OBJECTIVE(S)

This study aimed to estimate minimum clinically important difference (MCID) and substantial clinical benefit (SCB) among a large and diverse patient population regarding sex and age.

METHODS

In this study, 162 patients participated from five hospitals. MCID and SCB in pain, functional disability and quality of life were examined with anchor-based methods. Patients' global impression of change was used as the anchor. Area under the curve (AUC) values were determined for testing accuracy. Changes from baseline and coefficient of variation by responsiveness status were calculated to explain the results of accuracy.

RESULTS

SCB was estimated to be 2.18 for the numeric rating scale (NRS) for pain (AUC: 0.80 [95% CI: 0.72-0.88]) in all patients and 2.50 in women (AUC: 0.81 [95% CI: 0.71-0.89]). The estimated SCB of NRS for discomfort (1.50) and Jaw Functional Limitation Scale for mastication (1.35) had wide CIs for AUCs. Likewise, the estimated MCIDs of NRS for pain (0.80) and NRS for discomfort (1.50) had wide CIs for AUCs. Among non-responders who did not achieve the MCID of NRS for pain, the coefficient of variation was very high for all outcomes other than the NRS for pain.

CONCLUSION

This study investigated the responsiveness of patients with TMD using a large and diverse patient sample. SCB in pain decrease can be used to assess the responsiveness of patients with TMD. Composite outcomes should be developed to estimate MCID.

The reliability and minimal detectable change of common tests and measures for temporomandibular disorders

BACKGROUND

Temporomandibular disorders are a source of orofacial pain. Understanding clinimetric properties of evaluation procedures is necessary for assessing impairments and determining response to interventions.

PURPOSE

Reliability, minimal detectable change (MDC95), and 95% limits of agreement of TMJ examination procedures were investigated.

METHODS

Occlusion (central incisor alignment, overjet, overbite), mandibular dynamics (maximal incisor opening, laterotrusion, protrusion active range of motion (AROM)), auscultation, tenderness, and joint play were measured on 50 asymptomatic adults (30 females), mean age 24.8. The inter-rater reliability assessment used an intra-session design. Participants returned 24-48 h later for intra-rater assessments. Intraclass correlation coefficients (ICC) and Kappa values were used to determine reproducibility.

RESULTS

Intra-rater reliability for occlusion and AROM was ICC 3,1 ≥ 0.75, whereas interrater reliability was ICC 2,1 ≥ 0.68. Kappa values for inter-rater agreement of joint mobility was K = .18, whereas auscultation and palpation were K ≥ 0.48. Intra-rater Kappa values were ≥ 0.24, with lateral pterygoid region palpation having poor agreement. The MDC95 for occlusion was 1 mm, whereas AROM ranged from 3 to 6 mm. Mean AROM differences between raters were -1.16, -0.42, -0.18, and -0.8 mm for maximal incisor opening, left and right laterotrusion, and protrusion, respectively.

CONCLUSION

AROM and occlusion measurements may be used with confidence; however, poor agreement for joint mobility measurements and lateral pterygoid region palpation must be recognized. When re-assessing measurements, a 3-6 and 1-mm change in AROM and occlusion, respectively, is required to be 95% certain change is not due to error. Future symptomatic population research is needed (250/250).

Performance of key physical tests for temporomandibular disorder via telehealth: Establishing validity and reliability

BACKGROUND

During the COVID-19 pandemic, many individuals sought healthcare virtually. Physiotherapy is integral in managing temporomandibular disorders (TMDs); therefore, establishing how key physical tests can be appropriately adapted to telehealth is paramount.

OBJECTIVES

To establish the validity and reliability of telehealth (specifically videoconferencing) assessments against in-person assessments on a battery of TMD physical tests.

METHOD

A repeated-measures study design was undertaken. Thirty-six adult participants (19 healthy and 17 TMD) underwent concurrent temporomandibular joint (TMJ) physiological movement measurements via videoconferencing and in-person as per standard clinical practice. Inclusion criteria included the presence of central incisors and no significant comorbidities precluding a safe telehealth examination. Participants with TMD completed seven additional pain provocation physical tests.

RESULTS

Agreement between telehealth and in-person physiological movement measures was excellent (ICC >0.90, 95% CI: 0.53 to >0.99). Inter- and intra-rater reliability for telehealth measures indicated excellent reliability (ICC >0.97, 95% CI: 0.91 to >0.99). Exact agreement between telehealth and in-person for provocation tests ranged between 58.8% and 94.1%. Fourteen of the twenty-six individual measures produced substantial to near perfect agreement (PABAK = 0.65-0.88), seven produced moderate agreement (PABAK = 0.53), while five produced poor to fair agreement (PABAK = 0.18-0.29).

CONCLUSION

There is high level of agreement between telehealth and in-person measurements of TMJ physiological movement and pain provocation tests.

Test-retest reliability of the isometric contraction test (IC test) of the masticatory muscles in subjects with and without temporomandibular muscle disorders

OBJECTIVE

Recently, the DC/TMD has become an essential tool for the diagnosis of temporomandibular disorders (TMD). However, as they fail to include functional activities, new assessment proposals have emerged, such as the isometric contraction test (IC test) of the masticatory muscles, which uses muscle contractions to identify muscular TMD. This study aimed to determine the test-retest reliability of the IC test.

METHODS

A total of 64 participants (40 women and 24 men) completed the IC test administered by two different physical therapists on two non-consecutive days. Cohen's kappa (k), PABAK, and percent agreement (PA) between days were estimated.

RESULTS

The IC test showed good to excellent test-retest reliability values (k>0.77; PABAK>0.90), both globally and individually for the muscles evaluated, and PA>90%, therefore above the thresholds for clinical applicability. However, the global assessment of myofascial pain and the evaluation of the medial pterygoid muscle showed slightly lower reliability values.

CONCLUSION

The IC test is reliable for the assessment of subjects with muscular TMD, both in terms of the global assessment and the evaluation of each muscle, which supports its clinical applicability. Care should be taken when assessing myofascial pain globally and when evaluating the medial pterygoid in all types of pain.

Validity of the Isometric Contraction Test of the Masticatory Muscles for Diagnosis of Muscular Temporomandibular Disorders

In recent years, the Diagnostic Criteria for Temporomandibular Pain Disorders (DC/TMD) has been questioned, mainly because of the dependence on the muscular pressure needed to be applied during the clinical examination. Therefore, it is necessary to establish improvements in diagnostic strategies for DC/TMD of axis I. The aim of this study was to determine the validity of the Isometric Contraction Test of the masticatory muscles (ICTest) to diagnose DC/TMD of axis I. Forty (n = 40) patients with muscular TMD (myalgia in any of its subtypes), as well as forty age and sex matched controls, participated. They were diagnosed according to DC/TMD of axis I and performed the ICTest in a single session. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV), and positive (LR+) and negative likelihood ratios (LR−) of the ICTest compared with the DC/TMD of axis I were calculated. The ICTest showed a specificity of 95% for the diagnosis of myalgia, and between 94.9% and 96.8% for all subtypes in relation to the DC/TMD of axis I. For sensitivity, lower values were obtained, that is, 90.0% for myalgia, and losing sensitivity depending on the type of myalgia. The LR+ was over 10 for all diagnoses, with the exception of myofascial pain with referral, which was lower. When addressing the LR−, the myofascial diagnosis was the only one below 0.2. According to the results, the ICTest could be considered a valid procedure to diagnose subjects with muscular TMD in a clinical setting.

The Dental stick test - Useful to reveal intra-articular conditions in persons with temporomandibular disorder?

BACKGROUND

There is a need for clinical tests that can reveal intra-articular conditions in the temporomandibular joint to be able to give proper treatment. The Dental stick test, where participants bite with their molars on a wooden stick, is a pain provocation test for the temporomandibular joint.

OBJECTIVE

The purpose of this study was to explore if the Dental stick test can be used to reveal intra-articular conditions in the temporomandibular joint in persons with long-lasting painful disorders.

DESIGN

Cross-sectional.

MATERIALS AND METHODS

Forty persons with pain in one or both temporomandibular areas were examined using the Dental stick test. The participants were between 18 and 70 years, and had 65 symptomatic joints. Sensitivity, specificity, false positive and false negative responses, and area under the curve were calculated for the Dental stick test with MRI and/or CT as reference standards. The phi-correlation coefficient (phi) was used to measure the correlation between the Dental stick test and intra-articular findings.

RESULTS

The sensitivity and specificity for the Dental stick test, revealing intra-articular findings, were 0.62 and1.0 respectively. False positive and false negative responses were 0 and 0.41 respectively, and the area under the curve 81% with p < 0.001. The correlation between a positive Dental stick test and intra-articular findings was not significant (phi = 0.60).

CONCLUSIONS

When the Dental stick test is positive, intra-articular findings will most probably be present on MRI/CT, but the test alone cannot reveal intra-articular conditions in persons with long-lasting painful temporomandibular disorder.

Effect of Manual Therapy and Therapeutic Exercise Applied to the Cervical Region on Pain and Pressure Pain Sensitivity in Patients with Temporomandibular Disorders: A Systematic Review and Meta-analysis

OBJECTIVE

To assess the effectiveness of cervical manual therapy (MT) on patients with temporomandibular disorders (TMDs) and to compare cervico-craniomandibular MT vs cervical MT.

DESIGN

Systematic review and meta-analysis (MA).

METHODS

A search in PubMed, EMBASE, PEDro, and Google Scholar was conducted with an end date of February 2019. Two independent reviewers performed the data analysis, assessing the relevance of the randomized clinical trials regarding the studies' objectives. The qualitative analysis was based on classifying the results into levels of evidence according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE).

RESULTS

Regarding cervical MT, MA included three studies and showed statistically significant differences in pain intensity reduction and an increase in masseter pressure pain thresholds (PPTs), with a large clinical effect. In addition, the results showed an increase in temporalis PPT, with a moderate clinical effect. MA included two studies on cervical MT vs cervico-craniomandibular MT interventions and showed statistically significant differences in pain intensity reduction and pain-free maximal mouth opening, with a large clinical effect.

CONCLUSIONS

Cervical MT treatment is more effective in decreasing pain intensity than placebo MT or minimal intervention, with moderate evidence. Cervico-craniomandibular interventions achieved greater short-term reductions in pain intensity and increased pain-free MMO over cervical intervention alone in TMD and headache, with low evidence.

Multiple diagnoses, increased kinesiophobia? - Patients with high kinesiophobia levels showed a greater number of temporomandibular disorder diagnoses

OBJECTIVES

The aim of this study was to empirically derive subgroups according to pain-related fear of movement beliefs using cluster analysis within a sample of TMD patients and asymptomatic volunteers.

METHODS

129 volunteers participated in this cross-sectional study (34.78, standard deviation [SD]: 12.49 years; 92 TMD patients and 37 symptom-free volunteers). Mechanical pain sensitivity through pressure pain threshold (PPT) on orofacial and remote sites, kinesiophobia, pain catastrophizing, anxiety and depression were assessed. A cluster analysis was used to derive subgroups according to kinesiophobia scores (TSK/TMD).

RESULTS

Three subgroups were derived: cluster 1 (high kinesiophobia [n = 53], TSK score: 33, SD[standard deviation] = 2.9), cluster 2 (moderate kinesiophobia [n = 50], TSK score: 26.2, SD = 2.14) and cluster 3 (no/low kinesiophobia [n = 26], TSK score 12.12, SD = 2.08) which included patients with higher overall PPT and lower scores on psychosocial variables. The group with high kinesiophobia showed high levels of pain catastrophizing, anxiety, and orofacial pain-related disability compared to the other subgroups and mechanical pain hyperalgesia in remote site compared to the low-kinesiophobia group. Also, we found a greater prevalence of triple diagnosis for the high-kinesiophobia subgroup compared to the moderate kinesiophobia group - odds ratio: 12.6 (95% confidence interval [CI]: 3.31-43.52, p < 0.01).

CONCLUSION

These results suggested that patients with TMD and higher levels of kinesiophobia beliefs may show a more complex clinical feature, with high psychosocial distress, widespread mechanical pain sensitivity, and a more complex TMD disorder. In this way, we suggest a relationship between the number of TMD diagnoses and kinesiophobia severity.